This is a question I see posed on a regular basis in the press. It is clearly a topic of intense interest to the aging population, and it is worthy of a careful answer. As a starting point, it is useful to consider the three component parts of human memory:

1. Working memory is sometimes called attention span, and refers to information to which you have been exposed during the last minute or two. This information is held in the frontal lobe of the brain and, as far as we know, not stored for later retrieval. Recalling a phone number just long enough to dial it is a good example of working memory.

2. Short-term memory refers to information that you find novel or interesting, and store for later retrieval. This memory lasts from a few minutes to a couple of weeks, and is processed in the medial temporal lobe of your brain. Short term memory is used to recall your room number during a week-long stay in a hotel.

3. Long-term memory can last up to a lifetime. The name of your home town, the color of your first bike, and the name of your first pet are likely to be stored in long term memory.

We still have much to learn about memory formation, storage, and retrieval. However, with regards to memory loss, here are a few things we know:

It is never normal to experience severe or sudden changes in memory capacity. Any decline severe enough to interfere with your normal, daily activities is likely due to some underlying medical condition.

Working memory declines slowly with time, starting at around age 40. As such, a person who can read a ten-digit phone number and then successfully recall it for dialing, might someday need to break that phone number into three short chunks, and dial each separately. This does not indicate the presence of an illness.

Both long-term and short-term memory processing tends to slow with age. This means that you might search longer for the right word or for a person's name as you get older. This is true even for a healthy brain.

Hearing and vision can both decline with age and, when this happens, the brain may need to devote more resources to deciphering what it sees and hears. This additional activity distracts from storing information, so some perceived memory loss is actually due to distraction.

Healthy Brain Checklist
If you are concerned about your memory, you might be interested in a free questionnaire called the Healthy Brain Checklist that you can download from Medical Care Corporation. It allows you to tick off the types of memory concerns you have, and see if they are likely to be caused by an underlying medical condition, or if they are more likely due to the normal aging process.

Remember, many conditions can cause memory loss, including thyroid malfunction, sleeping disorders, medicines, depression, infections, and vitamin deficiencies. Of course more serious problems like Alzheimer's disease, stroke, and head trauma can also cause memory loss, but all can be treated best if detected early. So if you have a concern that seems correlated with a medical condition, be sure to discuss it with your physician.

Also, if your physician does not take your concern seriously, and your symptoms do not seem to be correlated with normal aging as described above, seek a second opinion from a different physician.

Consistent with our theme of clarifying the news about brain health, we are sharing an excellent video today from Medicare-Sherpa.

While the topic of Medicare is not exactly "brain health", most become Medicare eligible at age 65, which is about the time we see an increase in risk for brain related disorders. The video is very well done and completely demystifies the the components of Medicare's overall system.

I first saw this video at the GracefulAging website, which is another great resource worth looking into.

Earlier today, I made the case that the recommendations from the Alzheimer's Society might be inadequate. They have advocated for dementia screening in persons over age 75, which is a step in the right direction. But as I wrote in Part I of this post, the dementia stage is too late; we need earlier intervention.

I posted those thoughts after reading about the new recommendations, in this BBC article, which includes a second discussion that I think should be explored. It is the discussion about how to interact with patients who prefer not to know about their cognitive health. Unfortunately, the dogma of the 1990's, when it may have been better "not to know", still persists a decade later, when we are sure that early intervention against all causes of cognitive decline is beneficial.

While that concern about interactions with unwilling patients cannot be dismissed, I would like to offer a constructive perspective on how to think about cognitive assessment in medical practice. When a patient has a concern about their memory or other cognitive functions, and they visit a doctor to express those concerns, they have already declared their "wish to know". Those who would prefer ignorance do not seek their doctor's advice and care.

Certainly, physicians should not submit their patients to unwanted tests about concerns that their patients choose not to address. In that regard, automatic testing at a certain age, would carry some complications. But I don't think that is what anyone is suggesting. We merely need to arm physicians with the proper tools and the appropriate guidelines, so that when memory concerns are raised, they know how to intervene most beneficially.

I like to support clear steps in the right direction, but I have mixed feelings about the Alzheimer's Society recommending that physicians screen their patients for dementia beginning at age 75.

Granted, it is difficult for even the greatest physicians to address additional health concerns, outside of those that brought the patient to the clinic, during a typical visit. The structured nature of most health care interactions simply does not allow enough time for such exploratory activity. Since few patients visit a physician about a memory or cognition concern, until the problem is severe, most early stage problems are never addressed in primary care.

This leads to very late detection of cognitive problems and poor treatment outcomes based on late intervention. From that perspective, the Alzheimer's Society has taken a laudable approach to improving care.

However, my problem with their recommendation is that it hinges on the term dementia, which refers to a state of such severe impairment, that a patient is no longer able to care for themselves without human assistance. Even the term "early dementia" means that the threshold of severity has been crossed, and the patient's cognition is so poor that it has hampered their ability to function in daily activities. For most patients, and most causes of dementia, this is likely to be too late for meaningful intervention.

To improve care and keep our aging population cognitively intact, we need to detect more subtle symptoms so as to treat the underlying causes before a person becomes demented. This is the only way to preserve "high quality of life" and to contain the exorbitant costs associated with caring for demented populations.

Excellent tools for evaluating cognitive health and for detecting subtle signs of decline are available to primary care physicians. Contrary to the statement in the BBC article to which this post is linked, these assessments take only a few minutes and fit soundly within the logistics of a primary care practice.

I applaud all efforts to encourage the evaluation of memory and cognitive function in the physician's office, but I emphasize that these efforts must focus on detecting problems early enough to treat them effectively.

Some minor forgetfulness, like inability to recall a particular word or entering a room and forgetting why, is pretty common, even in healthy people over the age of forty. However, more severe symptoms may indicate the presence of an underlying medical condition. Among the many known causes of memory loss, all can be treated with some degree of success, and most can be completely cured.

While we often mention depression, medications, and thyroid disorders among the very treatable causes of memory loss, sleep disorders should also be on that list of common and treatable conditions. A great article about this very topic was posted today on CNN's health blog, the Chart.

Sleep apnea, or interrupted sleep due to lapses in breathing, is fairly common, especially in middle-aged and older men. It can be diagnosed with high certainty in a sleep study, and generally treated with good results. If untreated, sleep patterns can severely degrade, and chronic sleep deprivation can significantly impair alertness and cognitive function.

Given the prevalence of sleep apnea and other sleeping disorders, many worrisome signs of memory loss may be attributable to these treatable conditions. Please keep this in mind if you are worried, or know someone who is worried about their memory, and may not be sleeping well.

A great post today in the Productivity501 blog, describes 7 Ways to Upgrade Your Brain. Given all of the commercial activity hyping computerized brain games, I thought the suggestions in this well written article were refreshingly natural.

I encourage you to click through and read the article as each of the suggestions is thoughtfully supported with excellent examples. At the top level, the "7 Ways" are:

Read

Get a degree

Seek out new experiences

Think

Practice

Write

Do things that are hard

One fantastic activity for exercising the brain that is not mentioned here, but is validated with a growing body of scientific evidence, is socialization. Particularly, socialization in and among groups, where new relationships will be formed and cultivated.

Apparently, the social accounting required to assess a person's trustworthiness and value as a friend, demands a high level of thought, memory, and alternative scenario imagination. All of these activities engage the brain across many regions and realms of cognition. Had the author of the "7 Ways" post covered this topic, his examples might have included joining groups, clubs, or volunteer organizations where the activities require teamwork and communication with the other members.

The message in this post may be one of the most important that the Brain Today blog regularly supports. Alzheimer's treatment is more effective than the typical news story reports.

This is evident by the news from the UK today, where their governing health authority, the National Institute of Health and Clinical Excellence (NICE), extended coverage of approved drugs for Alzheimer's patients in earlier stages of the disease. Authorities cited "better evidence" about treatment efficacy as the key motivator for the decision.

In general, the misconception about treatment effectiveness is based on three misleading frames of thought:

Drugs don't treat the disease, they only lessen the symptoms
Many well done studies support the claim that approved drugs offer no disease delaying effects. The problem with this frame of thought is that all of the studies have been conducted on patients who are demented due to Alzheimer's. Based on the long disease course, this means they are in a very advanced state of disease progression, and have already accumulated massive damage in the brain. As such, it is not surprising that drugs cannot delay disease progression when treatment is initiated at such a late stage. It stands to reason, and most experts agree, that the earlier stages of the disease are much more treatable.

The beneficial effects of drugs on symptoms last only a year or less
Again, there are many well done studies that support this notion. However, the studies isolate "drug treatment" in order to measure its effects, whereas in the real world, Alzheimer's treatment involves more than a drug. A robust treatment regimen includes proper diet, physical exercise, proper management of hypertension and diabetes, intellectual stimulation, social engagement, and an educated caregiver. Many patients derive meaningful, long-term benefits from such an approach, especially if the intervention is begun at an early stage of the disease. A drug alone may not be an effective treatment, but effective treatment does not consist of a drug alone.

There is no cure
This is absolutely true. But the public has a tendency to interpret that statement to mean "there is no treatment". For perspective, there is no cure for hypertension or for diabetes, but we commonly treat them, and the public generally acknowledges the benefits of such treatment. For sure, the efficacy of our Alzheimer's treatments pale in comparison to the efficacy of our hypertension/diabetes treatments, but we need a healthy appreciation for the difference between treatment and cure for Alzheimer's disease.

I hope this high level decision by the health authority in the UK will foster a growing optimism and a more clear perspective on treatment efficacy for Alzheimer's disease. I concur that we need better treatments than those available today, but we also need the public and the medical community to embrace a more constructive view of what can be done now.

As we have described in earlier posts, the blood-brain barrier is a key protective mechanism in many animals, including humans. It effectively protects the central nervous system from contaminants in the blood stream while allowing necessary nutrients and oxygen into the brain.

While the blood/brain barrier is a marvel of protective design, it poses a major hurdle in delivering therapeutic drugs to the brain. Despite decades of research on various novel approaches, scientists have yet to find an efficient method for crossing this barrier. Several of these approaches were recently described in a Boston Globe article that we summarized here.

Earlier this week, scientists from the University of Oxford published a study in Nature Biotechnology detailing a new approach to this challenge. They appear to have delivered specific proteins across the blood/brain barrier by fusing them with exosomes, part of the body's natural system for transporting particles between cells.

At the basic science level, this seems safer than other methods for compromising the barrier because it seems to allow only for specific and intended breach of the protective system. Other approaches have had limited success in penetrating the barrier, but unfortunately, usually at the expense of letting unintended toxins pass into the brain as well.

Last week we described new evidence that Alzheimer's disease may begin outside of the brain. That was an interesting story partly due to the difficulty of treating diseases on the other side of the blood/brain barrier, as Alzheimer's has always been considered. If we can one day deliver drugs more effectively to the brain, then the location of origin for any particular brain disease, will be less important in terms of treatment.

Each year, the National Alzheimer's Association compiles facts and figures about Alzheimer's disease and releases a report that is both impressive and scary. The 2011 report was issued earlier this week and can be downloaded here.

I encourage you to download the report and read it. Here are a couple of the things that struck me:

As recently as two years ago, most estimates of the annual cost of the disease to the US economy, were about $100B. Many considered that estimate to be high and questioned its validity. With arguably tighter measures yielding a more accurate estimate, this report has placed the annual cost of Alzheimer's disease at $183B. That's "B" as in "Billion".

Alzheimer's is the 6th leading cause of death in the US. That is not startling. However, the other 5 leading causes are all declining while deaths due to Alzheimer's disease increased by 68% last year. That is eye-opening.

There are an estimated 15 million unpaid caregivers for Alzheimer's patients in the US. That's about 3 times as many unpaid care caregivers as there are patients. This is clearly a disease that is not being effectively managed through more traditional health care channels and services.

This is a carefully researched and well prepared report. I encourage you to download it and get familiar with the magnitude of the growing burden this disease carries. It is sobering, but we all must face it.

There is some great advice in the Huffington Post regarding 6 well-validated approaches to maintaining a healthy brain. Each of these has been covered to some extent in past posts here, but this is a nice presentation of the evidence in one article.

While I would recommend that you click through and read the full article, the 6 tips are listed here as an overview:

Manage chronic conditions under your control

Incorporate Mediterranian diet

Stay physically active

Avoid Tobacco Smoke

Stay intellectually and socially active

Watch for signs of Depression

Each of these is well within your control and proven to reduce your risks for cognitive decline.

If you were able to pass these 3 tests, you have a good ability to "stop seeing the pattern" and see the underlying elements. This is more interesting once you understand how powerful the brain is at pattern recognition. Let me demonstrate it below:

Can you raed this? Olny 55 plepoe out of 100 can.

I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it dseno't mtaetr in what oerdr the ltteres in a word are, the olny iproamtnt tihng is that the frsit and last ltteer be in the rghit pclae. The rset can be a taotl mses and you can still raed it whotuit a pboerlm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the word as a wlohe.

Now that you realize how adept you are at avoiding the details in order to make sense of the whole, you should really appreciate your ability to pick out the "C" and the "6" and the "N" from the test above. By the way, did you notice anything strange about the photo at the top?

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So what should we make of the many studies, including a new one published last week in Age and Ageing, that shows a lower incidence of dementia among those who drink light or moderate amounts of alcohol?

First we should note that many earlier studies have suggested similar findings. In general, cumulative scientific evidence, supporting the same conclusion, builds a compelling case. In that regard, the findings that alcohol consumption may somehow protect against dementia, should not be lightly dismissed. After all, part of the scientific discipline is having an open mind when faced with seemingly contradictory evidence.

On the other hand, most recognize that it has been exceedingly difficult to untangle the many confounding factors in these studies. For example, in this latest publication, the authors found that the subjects who reported themselves to be drinkers, were also higher educated, less likely to be depressed, and less likely to live alone. All three of those characteristics are correlated with a lower risk for dementia.

This raises the question: are drinking habits and incidence of dementia both related to the same life style choices? It is plausible that higher educated people partake in better care throughout their lives, and arrive at the age of dementia risk with a lower probability. They might also be more likely to be in good health, have attained the economic status to support an active social life, and have more social opportunities to drink.

In other words, we cannot yet be certain that drinking alcohol leads to lower incidence of dementia. Perhaps, other factors cause low dementia incidence AND more social drinking.

Also keep in mind, there are no studies showing that alcohol helps your liver.

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Have we been looking in the wrong place? After all the years of studying the brain, could it actually be the liver that holds the root cause of Alzheimer's disease?

This intriguing question has been raised by a recent publication in The Journal of Neuroscience Research. The study, conducted by a joint team of researchers from Scripps Research Institute and Modgene, LLC, showed an interesting result in mice. The study found a high correlation between the accumulation of liver-based, messenger RNA, expressed for genes known to correlate with early onset Alzheimer's disease, and susceptibility to the disease. This suggests that some process outside of the brain, might be responsible for triggering the complex cascade of Alzheimer's pathology.

Importantly, a drug shown to reduce the amount of amyloid in the blood stream, also showed a reduction of amyloid in the brain. That would not be surprising, except for the fact that the chosen drug does not pass easily through the blood/brain barrier. Therefore, it is reasonable to conclude that amyloid load in the blood may be an important driver of higher amyloid levels in the brain.

This differs from the current understanding that amyloid plaques in the brain are formed from amyloid that was produced in the brain. In fact, most research on Alzheimer's treatments has been focused on reducing amyloid production in the brain, or clearing amyloid from the brain. The demonstration that amyloid may arrive in the brain from other parts of the body, may be the most important aspect of this exciting new research.

As is often the case with such novel findings, this is very early stage work that will require years of additional validation and refinement before meaningful conclusions can be drawn. However, it is an intriguing approach, and it expands our general scientific view of potentially effective avenues to treatment.

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Depression is widely misunderstood by many. For some reason, various misconceptions about its causes and its symptoms, have lodged themselves in the public psyche.

WebMD has posted an excellent slide show that sorts the facts from the myths, and provides an excellent overview of depression. Through a series of short simple snippets, the slide show debunks 9 myths and reinforces 9 facts that everyone should understand.

I recommend you click through to view the presentation, but I will share a sampling of their message here:

Myth: Depressed People Cry a lot

Fact: Exercise is Good Medicine

Myth: Depression is a Part of Aging

Fact: Depression Imitates Dementia

In the full slide show, each of these Facts/Myths is supported with a short summary of the scientific truth behind statement. It is an enlightening overview, well worth the 3 minutes it will take you to view it.

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If you have a medical symptom, should you go online and educate yourself before seeing your physician? A recent article at the Huffington Post makes the case that patients who do, often pose a great burden on their physician.

I am sure that may be true sometimes. In fact, this blog is dedicated to clarifying the online news about brain health because we recognize how much misleading information is available on the internet. But there is another side to this story.

Because medical knowledge leaps forward more broadly and more quickly than physicians can absorb it, there is a long lag between the "state of medical knowledge" and the "state of medical practice". Any conscientious physician will recognize this, and will welcome good sources of updated information. Importantly, patients are becoming increasingly viable sources of such information.

Overall, I agree that there is lots of misleading medical information online, and I agree that dispelling online myths is a new burden for physicians. But in a great many instances, a well informed patient can help a physician give much better care.

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Recent headlines probably overstate the case that it might be. Studies on how cell phones affect the brain have been conducted since cell phones were adopted by the masses, in the decade of the 90's. Some of the studies have been placating and others have been alarmist, but none have been meaningfully conclusive.

The latest study, published last week in the Journal of the American Medical Association, has been amplified in the general press, in ways that imply dangerous side-effects associated with cell phone usage. The study itself makes no such claims.

The key finding was that cell phones appear to stimulate metabolic activity in those brain cells nearest to the ear where the cell phone is held. Certainly, metabolic activity in and of itself, is not a bad thing; cells must metabolize energy to function. The pertinent question is whether or not such activity, in response to cell phone radiation, has any meaning.

The authors did not speculate on whether the observed metabolic activity was good, bad, or otherwise. From a scientific point of view, a case could be made for any of those three possibilities.

The best summary and reasoned perspective that I have read on this research, was posted by Dr. David Katz on the Huffington post. I strongly encourage you to click through, and read his cogent overview of what this latest study means, and what it does not mean.

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